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DOI: 10.56732/pensarenf.v27i1.257

Review article

How to cite this article: Dutra IN, Ferreira MHB. Internet as a source of information and health literacy in

pregnancy: a scoping review. Pensar Enf [Internet]. 2023 Aug; 27(1):92-99. Available from:

https://doi.org/10.56732/pensarenf.v27i1.257.

Internet as a source of information and health

literacy in pregnancy: a scoping review

Introduction

The social reconfigurations of the last few decades have changed the role of women in

society, moving them away from the extended family and reducing their time to build

supportive relationships, essential factors of informal support during the transition to

parenthood. This new reality led to the emergence of alternative informal sources of

support, namely the internet, currently constituting one of the main sources of health

information for pregnant women. However, it is not enough to have access to online

information to know how to apply in health decisions, it is also necessary to evaluate,

understand and interpret it, that is, it is necessary to have health literacy.

Objective

Map the existing literature on the relationship between the internet as a source of

information and the level of health literacy of pregnant women.

Methods

Population: pregnant women; concept: health literacy; context: internet. Primary and

secondary sources of qualitative and quantitative research were considered, as well as

unpublished literature, as master's dissertations.

Research in three stages according to the JBI methodology, using the databases Medline,

CINHAL, Web of Science, Google Scholar and Open Access Scientific Repository of

Portugal. Considered articles published since 2015, in Portuguese, English, Spanish and

French. Data extraction and analysis performed in a table elaborated according to the JBI

methodology, 2020.

Results

13 articles were included. Pregnant women with a higher level of health literacy conduct

more online health research, resorting more to formal sources and discussing the

information accessed with health professionals. Pregnant women with a lower level of

health literacy have more difficulties in understanding, evaluating and applying the

information accessed online, resorting more to sources such as blogs and social networks.

Conclusion

The level of health literacy of pregnant women has a decisive influence on the use of the

internet as a source of health information, being positively related to greater frequency of

use, recurrence to formal sources and discussion of the information accessed with health

professionals. In contrast, a lower level of health literacy is associated with greater difficulty

in evaluating and understanding the information accessed, requiring support from health

professionals. The level of health literacy of pregnant women should be considered for a

personalized recommendation of valid and reliable online information.

Keywords

Pregnant Women; Internet; Health Literacy.

Irina Neves Dutra

orcid.org/0000-0001-6922-2769

Maria Helena Bértolo Ferreira

orcid.org/0000-0002-6612-2700

Degree. Nursing Research, Innovation and

Development Centre of Lisbon: Lisbon, Portugal

Master. Nursing Research, Innovation and

Development Centre of Lisbon, Lisbon; Nursing

School of Lisbon, Maternal Health Nursing

Department, Portugal

Corresponding author:

Irina Neves Dutra

E-mail: neves.irina@campus.esel.pt

Received: 30.01.2023

Accepted: 06.06.2023

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DOI: 10.56732/pensarenf.v27i1.257

Artigo

Introduction

The transition to parenthood is a developmental transition

caused by a major life event

that begins before or during

pregnancy, leading the woman to start preparing herself

essentially through the search for information and self-care.

There are several factors that contribute and influence the

development of skills for the role of mother, namely social

support, which is an essential source of information,

understanding and emotional support.

However, society

has undergone reconfigurations over the last few decades,

with family networks being more distanced and women

playing increasingly significant roles in the labor market,

limiting the time available for the development of

meaningful relationships.

This reality has led to around ¾

of pregnant women globally resorting to alternative sources

of information and support, as the internet.

The internet, defined by The Oxford English Dictionary

as a global and interconnected computer network that

provides a variety of information and means of

communication, is a privileged mean of obtaining health

information, especially for people of reproductive age

becoming preferred over sources of information based in

interpersonal relationships,

such as the relationship

between health professionals and clients.

During the transition to parenthood, the main resources of

pregnant women are health professionals, family, friends

and, increasingly, the internet,

an information resource that

is growing exponentially, offering information in a fast,

accessible, personalized and anonymous way.

However,

the accessibility and availability of online information raises

questions related to its reliability and credibility, and even

with the suitability of the information for the person

searching for it.

Despite the existence of abundant health

information online, the one which is based on scientific

evidence, it is not easily accessible to the general public.

However, to make informed health decisions on a daily

basis, it is not enough to have the ability to access

information, it is also necessary to have Health Literacy, that

is, the knowledge, motivation and skills to access,

understand, evaluate and apply health information in

different everyday situations.

Health literacy is a tool to

empower people, which must be built and improved

throughout the life cycle,

helping them to manage their

health, enabling them to use information correctly and thus

obtain gains on a personal and social level, being a means

for social and human development.

It involves

psychological factors, such as personal motivation and the

perception of self-efficacy, social and environmental factors,

which influence decision-making and health behaviors,

promoting greater ability to deal with illness, more effective

use of health services and better understanding and control

of life situations.

The higher the level of health literacy, the greater the

prevalence of information-seeking behaviors in all available

means, namely the internet.

On the other hand, a low level

of health literacy is associated with less competence in

assessing the quality of health information that is accessed,

and it is in people with a lower level of health literacy that

there is a lower incidence of preventive behaviors and a high

rate of use of health services.

Regarding the search for online information, people with a

lower level of health literacy tend to be distracted by extra

elements of a website (such as links), to choose the first

answer to their question, not confirming its veracity. They

also have difficulty in identifying the differences between

high and low quality information and tend to give up the

search if do not quickly find the answer to what they are

looking for, disregarding information with complex and

technical words that are not part of their lexicon.

Therefore, the role played by health professionals is crucial,

as seeing their traditional relationship being remodeled by

new technologies,

they should promote the health literacy

of those they care for, understanding which new sources of

health information are used, mediating its use and taking

advantage of the potential of new communication and

information technologies, such as the internet, to expand

people's access to reliable health information.

Midwives have as one of their specific competences the care

of women inserted in the family and community during the

prenatal period,

promoting their health and well-being

and individualizing care according to their specificities, as

their level of health literacy.

Considering the internet as a

privileged source of information for pregnant women,

midwives should be familiar with the most used online

resources related to pregnancy, as well as direct women to

reliable sites,

enabling them to conscious and informed

decision-making throughout pregnancy.

Considering the growing use of the internet as a source of

health information by pregnant women, as well as the

existing asymmetries in the search for online information

between people with a higher and lower level of health

literacy, the objective of this Scoping review is to identify in

the existing literature the relationship between the level of

health literacy of pregnant women and the use of the

internet as a source of health information. To this end, the

following initial question was defined: What is the

relationship between the level of health literacy of pregnant

women and the use of the internet as a source of health

information?

Methods

A review protocol was created, registered on the platform

OSF Registries (https://osf.io/k8hea).

The following keywords were defined: pregnant women;

internet; health literacy.

A preliminary search was carried out in May 9, 2022 in the

systematic reviews database of the Joanna Briggs Institute

(JBI) and the Cochrane Database of Systematic Reviews,

and to date, no scoping reviews have been found on this

topic.

Inclusion criteria

The inclusion criteria were defined according to the

methodology of the JBI.

The types of participants were

94 | Dutra, I.

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pregnant women, the concept of interest, health literacy

and context, the internet as a source of information.

As sources of information, research studies of primary and

secondary sources of qualitative and quantitative research

were used, as well as unpublished literature, as master's

dissertations. The inclusion and exclusion criteria are

systematized in chart 1.

Chart 1 - Inclusion and exclusion criteria

Inclusion criteria

Exclusion criteria

Design of the

study

Research studies of primary and secondary sources of qualitative, quantitative

and mixed-methods research were used, as well as unpublished literature, as

master's dissertations

Articles published in English, Portuguese, French and Spanish

Articles published since 2015

Articles published in different languages.

Articles published before 2015

Population

Articles with pregnant women as population

Articles with postpartum woman or mothers of small

children as population

Articles with health professionals who care for

pregnant women who use the internet as a source of

information

Concept

Articles with the concept of health literacy

Articles about only one of the topics in study and not

both simultaneously

Context

Articles about the search of health information online

Search Strategy

The research process aimed to identify published and

unpublished primary and secondary research and it took

place between 9 and 14 June 2022. For unpublished

research, Google Scholar and the Open Access Scientific

Repository of Portugal were used, where the terms

pregnancy, internet and health literacy were searched,

aggregated with the boolean operator AND.

The research strategy was carried out in three stages, as

recommended in the JBI

methodology.

In the first stage, an initial search was carried out in the two

most relevant databases for the subject under study,

MEDLINE and CINAHL, through the EBSCOhost

platform. In this research, the terms pregnancy, internet

and health literacy were used, some articles were identified,

and the words included in the titles and abstracts, as well as

the indexing terms, were subsequently analysed. In the

second stage, an organized search was carried out in three

separate databases, MEDLINE, CINHAL and Web of

Science, using the set of keywords in natural language and

identified indexed terms. Each concept was researched as

the main one, as it was only intended to identify articles in

which they appeared as the main concept under study.

For each database, the terms indexed for the selected

keywords were identified and, when the existence of terms

with truncation was verified, they were aggregated

according to its relevance. The identified natural and

indexed terms are shown in chart 2.

Chart 2 - Systematization of keywords in Medline and CINHAL databases

Natural term

Indexed term

Medline

Truncation terms

Indexed term

CINHAL

Truncation terms

Population

Pregnant

Pregnant women

Expectant mother

Concept

Health Literacy

Context

Internet

Web archives as topic

Internet based

intervention

Internet of things

Internet access

Social media

Internet

Social media

World Wide Web

Gopher

Internet access

Internet connections

Internet protocols

Internet based

intervention

After identifying all relevant natural, indexed and

truncation terms for each keyword, they were aggregated

using the boolean operator OR. In the end, among all the

keywords already aggregated, their association was

performed with the Boolean operator AND. Database

search procedures are provided in Appendix I

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Artigo

(MEDLINE), Appendix II (CINHAL) and Appendix III

(Web of Science).

Articles published in English, Portuguese, French and

Spanish were considered. As time limits, evidence

published since 2015 was considered, given that the topic

of using new information technologies as a source of health

information is relatively recent.

In the third stage, the list of references of the selected

articles was analysed, in order to identify any interesting

articles for the subject under study.

Source of evidence screening and selection

The process of evidence screening and selection is outlined

in the following flowchart:

Figure 1 – Flowchart of the scoping review process.

Adapted from: Moher, D; Liberati, A; Tetzlaff, J & Altman,

D. Preferred reporting items for systematic reviews and

meta-analyses: the PRISMA statement. Ann Intern Med.

[Internet]. 2009,151 (4), 264-269. Available from:

https://doi.org/10.1371/journal.pmed.1000097.

The search to identify unpublished literature carried out in

the database of the Open Access Scientific Repository of

Portugal, did not identify any results. In the databases used

after the initial identification of articles through the search

for the defined keywords, the title, abstract and keywords

were read and analysed. Duplicate articles were then

screened, resulting in a total of 29 articles. Subsequently,

the list of references of the identified articles was analysed,

and no article was identified that met all the selection

criteria. The articles to be included in the scoping review

were then selected according to their relevance to the

subject under study, through the analysis of the title and

abstract. In articles whose relevance was not clear by

reading the abstract, an analysis of the full text was

performed.

During the evidence source selection stage, 16 articles were

excluded for not meeting the defined selection criteria; two

articles were excluded because their population was health

professionals who care for pregnant women who use the

internet, and the rest were excluded because they only

presented one concept and not both simultaneously.

Then, both authors, independently, selected thirteen

articles to be included in this scoping review.

Data extraction

The extraction of data from the selected articles was done

through a table, elaborated according to the JBI

methodology, with the objective of extracting relevant data

from the identified articles, mapping the existing evidence

on the relationship between the use of the internet as a

source of health information and the level of health literacy

of pregnant women. Ethical aspects were preserved

throughout the data extraction process, with all authors

duly referenced and the content of the included articles

presented in a reliable manner.

Results

In order to present the synthesis of the main characteristics

of the included studies, a table was elaborated, presented in

Appendix IV. Considering the existing asymmetries

between different levels of Health Literacy (HL) and the

use of the internet as a source of information

6,9,13

, the key

results of the present scoping review were coded into

higher and lower levels of health literacy, and are presented

in the following chart:

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Chart 3 - Coding of the key results of the scoping review

Author

Objective

Results

Relationship between Health Literacy (HL) level and internet as a source of

information

Lower level of health

literacy

Higher level of

health literacy

Implications for practice /

for health professionals

Hussey, L.; Frazer, C. &

Kopulos, M. (2016)

Analyse the impact of the

HL level of millennial

pregnant women on health

decision-making during

pregnancy.

Less ability to understand

and apply the information

accessed online;

Require support from health

professionals to understand

and apply the health

information they access

online.

The level of HL must be

assessed with validated

instruments to personalize

the information.

Fredriksen, E.; Harris, J. &

Moland, K. (2016)

Understand how online

discussion forums influence

maternal HL.

Interactions between

pregnant women in online

forums influence their level

of HL, increasing their

knowledge and health skills

and giving guidance in using

the health system.

Sayakhot, P. & Carolan-Olah,

M. (2016)

Investigate how pregnant

women use the internet to

obtain information related to

pregnancy.

Empowerment is needed

through the promotion of

information search skills.

Greater propensity

to search for

information online.

Should warn that the

information available online

does not replace contact with

health professionals.

Guendelman, S.; Broderick,

A.; Mlo, M.; Gemmill, A. &

Lindeman, D. (2017)

Understand the extent of

adoption and use of digital

tools; to identify the main

psychological factors that

motivate the use of

technology among

disadvantaged primiparous

pregnant women.

Less use of digital tools.

Increased number

of online searches

on health

information;

Greater use of

digital tools for

managing health

issues.

Should inquire about online

health information search

behaviours and assess skilss

in using online tools that

require HL;

Should define strategies to

eliminate inequalities between

women with different levels

of digital HL.

Vamos, C.; Merrel, L.;

Detman, L.; Louis, J. & Daley,

E. (2019)

Explore pregnant women's

experiences in accessing,

understanding, evaluating,

communicating and using

health information during

pregnancy.

3 components of HL were assessed:

Comprehension: information in current language;

audio-visual elements and personalized information;

Evaluation: multiple references; credibility of the

source and presence of sponsorships;

Application: conducting prior search online allows

the formulation of questions before the contact with

health professionals and making health decisions on

topics such as nutrition and physical exercise during

pregnancy.

Pregnancy is a privileged

period for promoting HL;

Prenatal health education

interventions should be

developed according to the

level of health literacy,

ensuring their accessibility,

understanding and

applicability.

Arcia, A.; Stonbraker, S. &

Warner, E. (2019)

Understand how

disadvantaged pregnant

women characterize their

digital information needs and

search processes; Identify

the inhibiting and facilitating

factors in this process.

It is a barrier to the correct

interpretation of health

information that is accessed

online;

It is associated with a lower

propensity to search for

information online;

It is associated with the need

for support to access reliable

online information.

Should reference online

formal sources of

information, especially for

women with a lower level of

HL.

Chung, K.; Cho, H.; Kim, Y.;

Jhung, K.; Koo, H. & Park, J.

(2020)

Determine associations

between pregnant women's

medical help-seeking

strategies, changes in medical

decision-making, and use of

online health information

with a focus on the

mediating effect of self-

efficacy on literacy.

Online search for

information in

formal sources;

Greater intention to

discuss with health

professionals about

the information

accessed online.

Šoštaric, M. &, Jokić-Begić, N.

(2020)

Understand the

phenomenon of health

information search online by

pregnant women.

It is associated with greater

difficulty in obtaining

information online.

It is associated with

more online

research;

Increased skills in

assessing the

accuracy of online

information.

Bäckström, C.; Chamoun, S.;

Tejani, S. & Larsson, V. (2021)

Explore parents perceptions

of digital parenting support

Online support tools should be able to be

individualized at different levels of HL;

Must be actively present in

online support tools,

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during pregnancy and the

first 18 months of parenting.

supporting people with

critical levels of HL;

Should enhance critical and

analytical skills, promoting

HL.

Donelle, L.; Hall, J.; Hiebert,

B.; Jackson, K.; Stoyanovich,

E.; LaChance, J. & Facca, D.

(2021)

To understand how digital

technologies contribute to

the experience of transition

to parenthood.

The overwhelming amount of information available

online makes it difficult to understand;

Pregnant women need to raise their HL level to

know how to identify reliable online sources.

Should promote digital HL

skills;

Should know to reference

reliable online sources.

Álvarez-Pérez, Y.; Perestelo-

Pérez, L.; Rivero-Santana, A.;

Torres-Castanõ, A.; Toledo-

Chávarri, A.; Duarte-Díaz, A.;

Mahtani-Chugani, V.;

Marrero-Díaz, M.; Montanari,

A.; Tangerini, S.; González, C.;

Perello, M.; Serrano-Aguilar,

P. (2022)

To determine the influence

of creating online courses on

improving the digital health

literacy of pregnant and

breastfeeding women.

Should promote skills to

assess the quality and

accuracy of information

available online;

Online courses can be a tool

to empower pregnant

women, allowing access to

valid and reliable

information.

Lesser use of online

information sources of

reference and greater use of

sources such as blogs and

social networks.

It is potentiated by

taking online

courses.

Bäckström, C.; Carlén, K.;

Larsson, V.; Mårtensson, L.;

Thorstensson, S.; Berglund,

M.; Larsson, T.; Bouwmeester,

B.; Wilhsson, M.& Larsson,

M. (2022)

To explore the use of digital

information sources by

expecting parents and how

their health during

pregnancy its influenced.

Lower level of HL is related

to individual difficulties in

searching for online

information.

Should consider the level of

HL to provide personalized

support;

Should develop online

information adapted to

different levels of HL.

Lu, Y.; Barret, L.; Lin, R.;

Amith, M.; Tao, C. & He, Z.

(2022)

To identify research gaps in

information needs related to

pregnancy and information

available from different

sources.

Is associated with less online

searches;

Associated with more

difficulties in accessing health

information available online.

The health information

available online should be

formulated for a basic level

of understanding, in order to

be comprehensible to all

levels of HL.

Discussion

This scoping review allowed mapping the existing scientific

evidence on the relationship between the two concepts

under study: internet and health literacy in the defined

population, pregnant women, concluding that the level of

health literacy of pregnant women has a decisive influence

on the use of the internet as a source of information. The

authors state that it is in pregnant women with a lower level

of HL that is verified less use of digital tools to search for

health information,

18, 19, 20

possessing less ability to

understand and apply the information accessed online, as

well as individual difficulties in search for information,

21,

requiring support from health professionals.

18, 23

It is also

in pregnant women with a lower level of HL that there is

less use of online formal sources and greater use of sources

such as blogs and social networks.

On the other hand, pregnant women with a higher level of

HL, carry out more searches for online health information,

19, 22, 25

having better skills in assessing the accuracy of the

information they access.

They tend to resort to formal

online sources and have greater intention of discussion with

health professionals about the health information they have

accessed.

Towards the existing asymmetries between pregnant

women with different levels of HL, strategies must be

defined by health professionals to eliminate the inequalities

that emerge in the use of the internet as a source of health

information.

In the first instance, they should assess the

level of HL with validated instruments to provide

personalized support

21, 23

and ask questions about online

health information search behaviours of pregnant women

whom they care for.

They should promote skills for

evaluating the quality and accuracy of information available

online

21, 24, 27

and be actively present in online support

tools,

developing health information in current language

and with audiovisual elements,

which is adapted to

different levels of HL.

As a limitation of the present scoping review, the location

of most of the included articles emerges, which come from

studies carried out in the United States of America, with a

smaller number of studies carried out in Europe,

emphasizing the lack of studies carried out in Portugal.

Given the relevance and timeliness of the topic, research

on the use of the internet as a source of health information

and the level of health literacy of pregnant Portuguese

women emerges as a need.

Conclusions

The articles included in this scoping review allowed

mapping the existing scientific evidence on the relationship

between the use of the internet as a source of health

information and the level of health literacy of pregnant

women, something that should not be overlooked by health

professionals who provide care for this population. The

level of health literacy of pregnant women has a decisive

influence on the use of the internet as a source of

information, being positively related to greater frequency of

use, recurrence to formal sources and discussion of the

information accessed with health professionals. In contrast,

a lower level of health literacy is associated with less use of

digital tools to search for health information, greater use of

informal online sources and greater difficulty in evaluating

and understanding the information accessed, requiring

support from health professionals. The level of health

literacy of pregnant women should be considered for the

personalized recommendation of valid and reliable online

98 | Dutra, I.

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information. Considering the relevance of the subject, there

is an urgent need to carry out further research, with the aim

of guiding health professionals to provide care that is

sensitive to the specificities of pregnant women in the 21

century.

Authors’ contributions

IND: Conception and design of the study; Data

collection; Data analysis and interpretation; Drafting the

manuscript.

MHBF: Critical review of the manuscript.

Conflicts of interest

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

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